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DisorderBody Dysmorphic

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Alizeh Khan, a 34-year-old Pakistani

public relations executive in Dubai

is a self-confessed plastic surgery

addict. “My first operation was when I was

24 and had a nose job. I loved the way it

changed my profile so after a year, I had a

chin implant from the same doctor here in

Dubai and was pleased with the results. But

I just couldn’t stop – by the time I hit 30, I

had a new jaw line to add more dimensions

to my face, as well as new cheekbones. I

was constantly told at work that I looked

amazing and this prompted me to go for

more procedures. I did Botox before the

lines formed, I had my lips plumped and

once my face was done I moved to my

body. By the seventh operation, my surgeon

was a little weary of me and advised I

stop and seek psychological help. This

really outraged me. I just wanted to look

my best and I felt he was implying that I

had a mental problem? Needless to say, I

switched doctors and now will be having

my legs sculpted as well doing something

with my breasts and buttocks.”

DefinedMore than mere narcissism, Body

Dysmorphic Disorder or BDD is a mental

condition in which a person is preoccupied

with minor or imaginary physical deformity

usually of the skin, hair and nose, such

as facial lines, marks, pale or dark skin,

thinning hair, excessive body hair, acne

scars, large or crooked nose, explains

Dr. Firas A. Hamdan, Board Certified

Consultant Plastic Surgeon at The Cosmetic

Surgery Clinic,

Lebanon. “The

person complains of

a defect in either one

or several features

of their body which

causes psychological

distress that cause

clinically significant

distress or impair

❝Demand for cosmetic surgery in Dubai has significantly increased by over 100 percent since last year. About 68,000 males and females visited cosmetic clinics in Dubai last year, according to the report of the Dubai Health Authority (DHA). The report suggested that of this 68,000, 13,000 were Emirati women and 2,000 were Emirati man. reported Emarat Al Youm.

❞

Dr. Firas A. Hamdan

From the surge in plastic surgery procedures to a size zero body popular culture’s ideal of beauty, is it any wonder that Body Dysmorphic Disorder is on the rise? Saadiya Ahmad investigates this perplexing condition...

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occupational or social functioning. And

while statistically this is equal among males

and females, as 70 percent of my patients

are female, I do see more females with BDD

in my practice.”

Dr. Tara Wyne, Clinical Psychologist/

Clinical Director at The LightHouse Arabia

Clinic adds that an individual suffering

from BDD can’t stop thinking about a

flaw with his/her appearance. “The illness

has sometimes been called ‘imagined

ugliness’ and the when you have BDD, you

intensely obsess over your appearance and

body image, and you seek out aesthetic

procedures to try to ‘fix’ your perceived

flaws, but never will be satisfied,” she says.

SignsOne red flag for a plastic surgeon that

may indicate BDD is that a patient may

come for consultation and explain that they

want several different procedures when

realistically they are not necessary at all,

says Dr. Qassim Ahli, Consultant Plastic

Surgeon at Dermalase Clinic. “These could

be concerns such as fat which is not at

all apparent, shape of the nose or breast

size,” he explains, as well as the individual

who is well informed about procedures and

keeps abreast of current trends. “Often the

individual has had surgery previously and

complains that it isn’t good enough and

may constantly try to look in the mirror or

at their reflection and pick flaws in things

which only they can see.” Other common

signs, points out Dr. Raj Kumar Gang,

Senior Consultant Plastic and Cosmetic

Surgeon at Ibn Nafees Hospital in Bahrain

include a lack of confidence due to the

feeling of not being good looking, the

individual may also suffer from insomnia,

depression, irritation and may altogether

shun socialising.

Yet statistics show that close to one

to two percent of the population struggles

with BDD, so does this mean that anyone

seeking plastic surgery is actually suffering

from BDD? According to Dr.. Francisco

de Melo, Consultant Plastic Surgeon at

the Aesthetica Clinic, Dubai, individuals

who present for cosmetic treatment have

some degree of body image dissatisfaction,

and that is the reason why they seek for

correction. “For me, the most important

diagnostic tool of recognising BDD is the

dimension and the degree of distress the

impairment causes,” he says, for example,

a slight nose defect is not a reason to

abandon school or a job. “Also most of

the cosmetic patients are self conscious

of an appearance

defect, but don’t

‘allow it’ to interfere

with their lives, and

are functioning

appropriately,” he

says. These are the

ones whom can be

helped by plastic

surgery, and for

who appropriate surgical procedures can

be beneficial in improving their body image,

appearance and self-esteem.

Plastic SurgeryFace lifts, Tummy tick, breast enlargement

or reduction – the procedures are endless,

but for some no amount nip and tuck will

ever make them feel better. According to

Dr. Ahli, liposuction is the most addictive

procedure because once one area has been

done; patients often want further areas

treated. “Breast surgery is also addictive.

Those who have already had an implant

may wish to go even bigger and even minor

procedures such as lip filler can compound

the obsessive tendency; however these are

much less traumatic and easy to reverse

providing a recognised product has been

used,” he says. Yet most BDD sufferers,

especially those who remain undiagnosed,

fail to recognise that their problem originates

in the brain, and instead, they mistakenly

believe that if they could only correct

their ‘deformed’ physical appearance,

all would be well, says Dr. Wyne, so they

seek out plastic surgery, assuming that the

surgeon will immediately see how severe

their defects are, and will correct them,

thereby magically transforming their lives.

“Yet unfortunately, people who suffer from

BDD are rarely satisfied with the outcomes

of their surgeries. They often obsess over

scars, or they may be driven to near-

madness over the slightest asymmetry

of the result while others shift their focus

to another perceived defect that was not

adjusted by the surgery,” she says.

PrevalenceDr. Gang points out that the link between

plastic surgery addiction and BDD is great

as the BDD sufferer will repeatedly seek the

advice of a plastic surgeon for procedures

done and dissatisfied with, whereas in fact,

one plastic surgery procedure will lead

to another and then another. And while

BDD can affect anyone, says Dr. Wyne, it

Dr. Tara Wyne

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most commonly develops in the teenage

years. When it arises it usually becomes

a chronic condition unless it is treated.

“Ultimately, there’s no sure way to prevent

body dysmorphic disorder as it often starts

in adolescence, identifying children at risk

of the condition and starting treatment early

may be beneficial.” In addition, taking steps

to control stress, to increase your resilience

and to boost low self-esteem are useful.

And while BDD patients tend to focus more

on the skin, hair and nose, there is also

some differences regarding the gender, says

Dr. De Melo. “Men are more preoccupied

with their genitals, height, hair and body,

where women show more concern about

weight, breasts, hips and legs.

Causes/TriggersBDD usually develops in teenagers at a

time when individuals are most concerned

about the way they appear to others, says

Dr. Wyne. “However, many patients suffer

for years before seeking help and there is

no single cause for this ailment. Genetic

pre-disposition does appear to be a factor

in determining who may develop BDD,

however environmental factors can also

have an effect including severe teasing by

peers.” Similarly to teasing, parenting style

may contribute to BDD onset; for example,

parents who either place excessive

emphasis on aesthetic appearance,

or disregard it altogether, may act as a

trigger in the genetically predisposed.

Other possible triggers include other life

experiences, such as neglect, physical and/

or sexual trauma, insecurity and rejection

as well as the individual’s environment and

culture. Also BDD can often occur with

Obsessive Compulsive Disorder (OCD)

where the patient practices unmanageable

habitual behaviours that may literally take

over their life, says Dr. Wyne.

EthicsYet where does the doctor draw the line at

outlandish repeated requests of “just one

more procedure?” Dr. De Melo responds,

“For me cosmetic surgery is like any

medical treatment where there is a problem

and different therapeutic alternatives to

treat it. We just have to find the one that

is more adequate to the particular patient.

If I cannot do any good or if I am not able

to perform what it is required, I just refuse

the patient or refer him to someone with

the right qualification to handle is problem.”

He adds that the ultimate goal of plastic

surgery is to enhance physical proportion

and to correct deformity. “And amongst

the cosmetic surgery patient’s population,

the incidence of BDD is higher in a range

from 3.2 to 16 percent. The BBD patient

will not be satisfied by a single correction,

as the problem doesn’t lie in the body but

in their perception of the body. Then after

the given procedure they will find another

problem to correct and to blame for their

lack of success and functional impairment.

He shares a case study of a 36-year-old

patient. “She visited my Lisbon office asking

The Quest for Eternal YouthCindy Jackson became famous for the unheard of amount of plastic surgery she has undergone. Cindy claims

to be the original extreme makeover and has written books about plastic surgery and what she has learned after

undergoing over 50 cosmetic procedures. She holds the official world record for “Most Cosmetic Procedures”, after

undergoing 52 cosmetic procedures by the age of 55. Cindy has spent approximately $100,000 on plastic surgery

that includes 14 actual operations (five full face lifts, lots of liposuction, two eye lifts, chin reduction, lip implants,

multiple boob jobs, nose job, cheek implants). The rest of the 38 cosmetic procedures are less invasive injectables

(Botox and fillers), chemical peels, cosmetic dentistry and semi-permanent makeup. Most recently, Cindy Jackson

had her hands injected with filler in an attempt to hide the veins and make them appear younger.

(Credit: http://famousplastic.com/category/plastic-surgery-addiction)

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for eyelid surgery which would have made it

her 34th surgical procedure and the second

one for the correction of excess skin around

the eyelids. I refused to do it on the basis

that there were no surgical indication for

it.” Exercising extreme caution, he and his

non-medical staff were able to get her in to

psychiatric counselling and end the endless

surgical spiral that she was going down.

MediaFrom airbrushed images to the clever use of

Photoshop, Dr. Ahli notes that unfortunately

the media play a huge role in exacerbating

BDD for those with a latent tendency. “We

are constantly fed pictures of near perfect

women who have been air brushed to

a degree that is completely unrealistic,”

he says. In addition, plastic surgery has

become the norm as the media feed us

more and more images of celebrities who

have gone under the knife and people

become affected by this. There is absolutely

nothing wrong with wanting to make small

changes to enhance your appearance

however, expecting to look like one of these

models in the magazines is not a healthy

expectation to hold,” he says. Dr. Wyne

adds that people with any personality traits

or vulnerability to developing BDD will be

more susceptible to images of perfection

in the media. “As they are so concerned

with their flawed appearance, they will

be making unfavourable comparisons

with beautiful flawless celebrities and

models and it can intensify their sense of

imperfection,” she says.

TreatmentTreatment for BDD usually entails a multi-

modal approach, beginning with cognitive

behavioural therapy, which attempts to get

patients to recognise irrational thoughts

and then challenge those thoughts with

more rational positive self-talk learned in

therapy, says Dr. Wyne. “Also effective is

a type of therapy called ‘exposure and

response prevention’, commonly used in

the treatment of phobias in which patients

may be asked to write a list of situations

they would normally avoid out of fear or

anxiety about their looks,” she says and

the goal is that over time, the patient will

begin to see the situation and others

like it in a more realistic light, thereby

rendering the situation less threatening

in the patient’s mind. The component of

treatment known as ‘response prevention’

is all about decreasing the incidence

of ritualistic behaviours that have been

previously used by the patient to deal with

anxiety-producing situations, she says and

these behaviours may include compulsively

checking the mirror, constantly adjusting

one’s outward appearance by applying and

reapplying cosmetics, picking at the skin,

or even forms of self-mutilation. Another

tool used to treat BDD is medication, she

says as BDD is a brain disorder which falls

under the diagnostic umbrella of “chemical

imbalances”. “The main neuro-chemical

involved in the manifestation of BDD is

Serotonin, therefore, the usual medications

of choice in treating BDD are SSRIs

(Selective Serotonin Reuptake Inhibitors),

traditionally used in treating depression and

anxiety, which are also common in BDD

patients,” she says.

Body Dysmorphic Disorder (BDD) – Fear of Imagined Ugliness

BODY DYSMORPHIC DISORDER SELF TEST

Do you have Body Dysmorphic Disorder (BDD)?

1. Are there any parts of your body that you feel are

unattractive or ugly? Yes ❏ No ❏

2. Do you find yourself thinking excessively about

your unattractiveness? Yes ❏ No ❏

3. Do you compare the unattractiveness of your body

part with the same body part or parts of others? Yes ❏ No ❏

4. Do you regularly check your unattractiveness in the

mirror in the hope that it may look better?Yes ❏ No ❏

5. Do you ask others about your unattractiveness? Yes ❏ No ❏

6. Do you use makeup to minimise displaying

to others the part of your body that you feel is

unattractive?Yes ❏ No ❏

7. Do you camouflage any parts of your body that

you feel are unattractive?Yes ❏ No ❏

8. Is your life compromised by concerns with your

appearance?Yes ❏ No ❏

If you answered YES to most of the above questions, you may have Body

Dysmorphic Disorder (BDD)

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